Photo provided by David R. Harris, PA PM, NR PM, AA, BA, Fire Officer IV, Instructor III 

A basic fall victim tested the skills of two paramedics with the Penndel Middletown Emergency Squad in Bucks County, Pennsylvania.

Incident 

Bucks County 911 Communications Center (BCC) dispatched the Penndel Middletown Emergency Squad (PMES), Medic 168 for a reported basic fall victim in the area of a local strip mall. Our medic unit responded and was staffed this day with two paramedics. We received further information via our mobile data terminal (MDT) enroute that the patient was reported to be in a vehicle in the parking lot with bystanders nearby.

On arrival, we found several police andbystander vehicles on location. Police advised the crew that there was a confused female bleeding from the lip, and a bystander, an EMT, was with the patient. The officer further stated that the patient had no identification on her, but they were able to find a card with her name on it and found out that the patient lives about 2.5 miles from the current location. No other information was found on the patient, or in her purse. We requested information from the bystanders and from the on-scene EMT, who stated they saw the patient trip over the curb and hit her face. She was first found sitting in the grass with minor bleeding from her lip.

The patient, a 72-year-old female, appeared to be very well cared for and was appropriately dressed for the chilly day. She was conscious and alert but was confused about who and where she was, the time, and current events. The patient weighed approximately 76 kg. By this time, the patient was standing at the bystander’s vehicle very anxious and upset, repeatedly saying: “I lost my brain.” Something did not seem right. The patient had what appeared to be a minor injury with no apparent loss of consciousness and kept repeating herself. Police were again asked if there was any information found on the patient or her belongings. They stated there was not. I then asked if there were any reports of a missing elderly female but there were not.

Assessment

Emotional support was provided to the patient and a spinal assessment was performed. That revealed no neck or back pain. The patient was able to follow commands so spinal motion restriction was not initiated. She was moved to the medic unit. Once there, we proceeded with our assessment and manual vital signs.

It found a blood pressure of 140/76, a pulse of 88, a respiratory rate of 16 with a GCS of 14, and a room air saturation of 98%. The patient was placed on the cardiac monitor which showed a sinus rhythm rate of 88.

A head-to-toe secondary assessment was performed and the only finding was a very small laceration to the patient’s bottom lip. The bleeding was under control. The patient offered no chief complaint and stated nothing was bothering her. She denied having a headache, neck pain, chest pain, shortness of breath, or back pain. The abdomen was soft and nontender, her pelvic region was fully intact with no pain or noted deformities, and all extremities were intact with no noted injuries, and had full flexion and extension with pulses palpable. In addition, lung sounds were normal with clear and equal symmetry, and her skin was warm and dry with a pink color. A stroke assessment was performed and no deficits were found as the patient followed all commands incorporating full flexion and extension.

Treatment

With nothing adding up, I then asked my partner to go through the patient’s purse again as I felt that this patient was a walk away. After checking all the compartments of the purse, my partner found a note in an outside zippered compartment that read: “My name is [redacted] and if I am found, I have dementia, please call my husband at [redacted].” We called the number but there was no answer, so we left a voicemail. We began transport to the local Level II Trauma Center. A finger stick blood glucose on the patient obtained a reading of 132 mg/dL. The patient was talking about her times at the New Jersey shore and I was holding pressure on the finger stick site. Then she began holding my hand, so I continued to hold hers. A second attempt to contact the patient’s husband was made. This time there was an answer and we confirmed that we had the husband of the patient. He stated: “Where did you find her? I have been out all morning looking for her.”

We confirmed the patient’s mental capability and he confirmed the patient had dementia. I presented my current assessment on the patient’s mental status to the husband and he stated her normal mental status included talking about the Jersey shore as they have a beach house. Furthermore, the patient loves to hold hands. Additional questioning of the husband regarding the patient’s past medical history revealed that the patient had Type 1 diabetes and was on Lispro. He also stated to us before the patient’s walk she was given her morning insulin and had eaten a full breakfast. The husband stated that the patient normally takes a short walk everyday around their street but today she didn’t come back. He was told we were transporting her to the hospital for evaluation and to meet us there so he could provide the necessary medical information.

The patient was reassessed throughout the transport with automatic blood pressure readings in the normal range, oxygen saturations 98% throughout; while ECG remained sinus with a rate in the 80s, and mental status evaluation was obtained through continued communication with the patient. We continued to discuss various New Jersey beaches and other shore towns while holding the patient’s hand, and her, in a comfortable position. A report was provided to the local trauma center with an emphasis the patient was stable, in her normal mental status, that all findings were negative, and there were no complaints by the patient.

We were met the patient’s husband at the hospital and he followed us to the emergency room. A report was given to the RN with follow up information by the husband, which also confirmed the crew’s finding on the mental status of the patient. The patient remained stable and comfortable throughout the transport and showed an obvious decrease in her anxiety and apprehension when we first encountered her. She was reunited with her husband and that obviously made both individuals very pleased.

Discussion

We then asked to discuss the incident with the patient’s husband outside of the patient’s room. We asked the husband to clarify the patient’s situation and what happened today. He reiterated the patient has dementia and usually takes a daily walk just on their street but she did not return. He told us the patient refuses to wear or carry any form of identification and he secretly placed the note we found in her purse in an obscure compartment. We recommended him placing a File of Life card in her purse which contains pertinent medical information, medications, and emergency contacts. The husband liked the suggestion and we provided it to him.

My partner said to me at the end of the call he would have transported that patient as a Level II Trauma patient base on her presentation. He complimented me for taking the time on act on my gut feeling since it saved the patient from increased apprehension, discomfort, medical bills, and numerous medical testing.

In the end, the patient was discharged from the hospital with no finding, no related injuries, or necessary follow-ups. The discussion now turns to how many responders would have taken the time to a) relate to the patient, b) follow their gut feeling , or c) transport the patient as either a trauma or stroke patient. If you did either of the latter, would you have been wrong?

A peer review Quality Assurance process, which is performed monthly at our organization and required by the Pennsylvania State EMS Act, reviewed the incident. The committee found no inappropriate patient care was performed during this call. The providers were recognized for taking the time to perform a full assessment of the patient and not taking the word of the police that no information was found regarding the patient. The committee also commended the EMS crew for following their gut instincts, providing an appropriate level of care, and more importantly, preventing the patient from having undue apprehension, anxiety, medical testing, and medical costs. PMES’s Medical Command Physician commended the providers with taking the extra time to care for the patient, preventing unwarranted mental anguish, and unjustified medical expenses. More importantly, he applauded the level of care, including the emotional support of holding the patient’s hand and talking to her.